Gynaecological problems Flashcards
How should the increased risk of endometrial hyperplasia in PCOS be managed?
Progestogens should be used to induce a withdrawal bleed at least every 3-4 months
How should women with PCOS be screened for T2DM?
If they have both PCOS and are overweight or have PCOS plus additional risk factors, they should be offered an OGTT
What is the link between PCOS and both breast and ovarian cancers?
There does not appear to be an association between PCOS and breast and ovarian cancer
What are the Rotterdam criteria for diagnosis of PCOS?
- polycystic ovaries with either 12 or more follicles, or ovarian volume >10cm
- Oligo-ovulation or anovulation
- Clinical and/or biochemical signs of hyperandrogenism
How can CAH be investigated for in rapidly progressing hirsuitism?
17-Hydroxyprogesterone is measured in the follicular phase and will be raised in CAH
If 17-hydroxyprogesterone is borderline, which test is used to confirm diagnosis of CAH?
ACTH stimulation test
What is the incidence of symptomatic ovarian cysts in premenopausal women being malignant?
1:1,000
What percentage of suspected ovarian masses are ultimately found to be non-ovarian in origin?
10%
What is the management of a simple ovarian cyst <50mm in a pre-menopausal woman?
Conservative: the majority will resolve over 2-3 menstrual cycles without intervention
What is the role of LDH, afp and hCG measurement in evaluation of cysts in pre-menopausal women?
Should be undertaken for all women under 40 with complex ovarian mass due to the risk of germ cell tumours
CA125 is primarily a marker for which ovarian cancer?
Epithelial ovarian carcinoma
Which scoring system does GTG advocate for assessing risk of malignancy and how is it calculated?
RMI 1:
RMI = U x M x CA125
1 point for premenopausal, 3 points for postmenopausal
1 point for ultrasound score 1, 3 points for ultrasound score 2-5
What are the sensitivity and specificity of using RMI 200 as a cut off for malignancy?
Sensitivity 78%
Specificity 87%
What are the sensitivity and specificity of using IOTA rules for classifying masses as benign or malignant?
Sensitivity 95%
Specificity 91%
What are the M-rules for IOTA classification?
Irregular solid tumour
Ascites
At least 4 papillary structures
Irregular multilocular solid tumour with largest diameter >=100mm
very strong blood flow
How should premenopausal women with simple cysts of 50-70mm be managed?
With yearly followup ultrasound
How should premenopausal women with simple cysts >70mm be managed?
Either MRI or surgical management
How should women with a cyst growing between interval scans be managed?
RMI score followed by operative management
What is the effect of COCP on functional ovarian cysts?
COCP does not promote the resolution of functional ovarian cysts
What is the range of recurrence rate for ovarian cysts following needle aspiration?
Between 53-84%
What are the first and second line investigations for pre-menstrual syndrome?
- Symptom diary
- GnRH analogues for 3 months
What 3 treatments should be trialed in primary care prior to secondary referral for pre-menstrual syndrome?
- COCP
- Vitamin B6
- SSRI
Which COCPs should be considered first line for pre-menstrual syndrome?
Drospirenone-containing COCP
Should COCP be taken continuously or cyclically for women with PMS?
Continuously
Which medications need to be used with caution for women with PMS?
Progestogens (though micronised progestogens may be better)
Which medication given for PMS requires barrier contraception and why?
Danazol; it may cause virilisation of a female fetus
Which monitoring test is required for women on long term GnRH analogues for PMS and how often?
DEXA should be performed yearly
What advice should women on SSRIs for PMS be given when they fall pregnant?
They should stop SSRIs in pregnancy as their PMS symptoms will cease
Why is bilateral oophorectomy without hysterectomy not recommended for management of PMS?
This would necessitate progesterone replacement for endometrial protection and would risk stimulating PMS
What percentage of women experience symptoms of PMS?
40%
Of women who experience PMS, what percentage (range) suffer from severe PMS?
5-8%
What is the most reliable questionnaire used for a PMS symptoms diary called?
The Daily Record of Severity of Problems
What is the daily dose of Vitamin B6 restricted to and why?
10mg due to risk of peripheral neuropathy at higher doses
What should women be warned of when using the Levonorgestrel-releasing IUS for the progestogenic component of PMS treatment?
The low levels of progesterone in the coil may initially cause some PMS symptoms
Which diuretic can be used for PMS symptoms?
Spironolactone
What is the lifetime prevalence of fibroids?
30%
Aside from ethnicity, what are the risk factors for development of fibroids?
Obesity
Nulliparity
What proportion of women with fibroids are symptomatic?
25%
By what percentage did fibroids shrink after 12 weeks of GnRH treatment in the Cochrane review?
36%
Why is Ullipristal Acetate no longer used for uterine fibroids?
Long term usage carriers a risk of liver failure
What is the Odds Ratio for reintervention after uterine artery embolisation compared to myomectomy?
10.45
How should a unilocular, simple ovarian cyst of less than 5cm diameter be managed in a postmenopausal woman, when the CA125 is low?
Surveillance ultrasound at 4-6 months
Can discharge after 1 year if no interval growth
What operation should be performed for a symptomatic postmenopausal woman with a simple, low risk cyst?
Laparoscopic bilateral salpingo-oophorectomy
What operation should be performed for a postmenopausal woman with RMI I >200?
Staging laparotomy
CA125 is raised in over 80% of which ovarian cancers?
Epithelial ovarian cancer
CA125 is not usually raised in which type of ovarian cancer?
Primary mucinous ovarian cancer
CA125 alone has a pooled sensitivity and specificity of what for differentiating benign from malignant masses?
78%
What are the 5 features of simple cysts on TVUSS?
- Round or oval shape
- Thin or imperceptible wall
- Posterior acoustic enhancement
- Anechoic fluid
- Absence of septations or nodules
What are the 3 ultrasound features of complex ovarian cysts?
- Complete septation
- Solid nodules
- Papillary projections
What percentage of simple cysts <5cm in postmenopausal women will disappear by 24 months?
53%
What features on ultrasound contribute to the “ultrasound score” portion of RMI?
Multilocular
Solid areas
Metastases
Ascites
Bilateral lesions
What is the sensitivity and specificity of RMI when a cutoff off 250 is used?
70% sensitivity and 90% specificity
What should be included in staging laparotomy?
Laparotomy
Cytology from either ascites or washings
TAH, BSO and omentectomy
Biopsies from any suspicious areas
What 5 criteria can be used to stratify risk of ovarian torsion?
- Unilateral lumbar or abdominal pain
- Pain duration <8 hours
- Vomiting
- Absence or leucorrhea/metorrhagia
- Ovarian cyst >5cm
Ovarian cysts are seen in what percentage of pregnancies?
up to 5%
How should cystectomy be performed in the context of torsion?
Interval cystectomy 2-3 weeks after detorsion
What proportion of TOAs occur in nulliparous women?
60%
What is the mortality rate of TOA when associated with severe systemic sepsis?
5-10%
What proportion of women being treated for proven PID will be diagnosed with a TOA?
15-35%
Which two symptoms/signs are more common in women with TOA than PID?
Fever
Diarrhoea
What is the most sensitive predictor of a TOA?
High CRP along with clinical signs
What is a cogwheel sign thought to be pathognomonic of?
Acute tubal inflammation
(as seen in TOA)
Which CT finding is usually associated with bowel-associated abscesses and is uncommon in TOA?
Internal gas bubbles
What structure, if seen entering an adnexal mass on CT, allows for differentiation between TOA and periappendicular abscess?
The ovarian vein
Which antibiotics have higher abscess cavity penetration and have been shown to reduce abscess size?
Clindamycin
Metronidazole
Cefoxitin
Which factors are associated with poor prognosis for recovery after TOA?
Abscess >5cm
Age >40
Smoking
Higher initial WCC
What is the likelihood of postmenopausal women with TOA having an associated malignancy?
47%
Why rare complications of TOA should be imaged for in women who do not improve following surgery with sustained pyrexia?
Subphrenic abscess
Intrathoracic abscess
What percentage of women with TOA who undergo percutaneous drainage are able to avoid surgery?
81%
Risk of pregnancy when removing an IUS/IUD from a woman with TOA should be considered if the women has had unprotected intercourse within how many days?
5
Which antibiotics does Actinomyces commonly respond to?
Penicillin
Approximately what percentage of women on HRT will experience unscheduled bleeding?
40%
What are the major risk factors for endometrial cancer?
BMI >=40
Lynch syndrome
Cowden syndrome
What are the minor risk factors for endometrial cancer?
BMI 30-39
Diabetes
PCOS
What are the options for progesterone regimes used as part of sHRT for women with a uterus?
minimum 10 days Norethisterone/Provera
or
12 days micronised progesterone
When should women be changed from sHRT to ccHRT?
After 5 years use or by age 54
How should a woman with unscheduled bleeding on HRT with no risk factors, occuring within 6 months of starting HRT or persisting 3 months after a change in HRT be assessed/managed?
Offer adjustments in the HRT or Progesterone preparation for up to 6 months
How should a woman be managed if she has unscheduled bleeding persisting beyond 6 months of HRT adjustments in the absence of risk factors?
Offer either:
a. Urgent TVUSS within 6 weeks
b. Wean off HRT and consider non-hormonal options
How should a woman be managed if unscheduled bleeding occurs more than 6 months after starting or more than 3 months after changing HRT, in the absence of risk factors?
Urgent TVUSS within 6 weeks
How should a woman be managed if she has unscheduled bleeding on HRT that either is heavy/prolonged, or if she has 2 minor risk factors for endometrial cancer?
Offer urgent TVUSS within 6 weeks
How should a woman with unscheduled bleeding on HRT with 1 major or >=3 minor risk factors for endometrial cancer be assessed/managed?
2WW referral
Adjust progestogen or stop HRT whilst awaiting assessment
How long can a woman be reassured by a normal pipelle endometrial biopsy?
3 months
How long can a woman be reassured following normal hysteroscopy and endometrial biopsy?
6 months
What is the most effective way of reducing unscheduled bleeding on HRT?
52mg LNG-IUS (Mirena)
How is chronic pelvic pain defined
Pelvic pain lasting >6 months and not solely associated with intercourse or menstruation
What is the evidence for adhesiolysis in management of chronic pelvic pain?
There is no evidence to support division of fine adhesions
Division of dense vascular adhesions is associated with pain relief and should be offered
Injury to which muscles may result in chronic pelvic pain which in some cases can be relieved with botox injection?
Levator ani
What is the percentage risk of nerve entrapment following one Pfannenstiel incision?
3.7%
Women experiencing bloating, early satiety, pelvic pain or urinary frequency or urgency more than how many times per month should have CA125 measured?
> 12 times per month
Which smooth muscle relaxant may be beneficial for chronic pelvic pain related to IBS?
Mebeverine
By what percentage of size can fibroids be expected to shrink by 12 weeks after Goserelin injection?
35%
What is the risk of RPOC following SMM?
4%
What is the risk of ureteric injury at laparoscopic resection of endometriosis with associated hydronephrosis?
20%
What are the IOTA B-rules?
Unilocular cyst
Presence of solid components where the largest solid component is <7mm
Presence of acoustic shadowing
Smooth multilocular tumour with a largest diameter <100mm
What are the IOTA M rules?
Irregular solid tumour
Ascites
At least 4 papillary structures
Irregular multilocular solid tumour with largest diameter >100mm
Very strong blood flow
What percentage of women will have vaginal discharge within 12 months of having uterine artery embolisation?
15%
What percentage of women will be asymptomatic or have significantly improved symptoms at 1 year post uterine artery embolisation?
80-90%
What proportion of women will need repeat treatment within 5 years of uterine artery embolisation?
1 in 3
What are the contraindications to uterine artery embolisation?
Pregnancy
PID
What is the rate of endometritis following uterine artery embolisation?
0.5%
What is the rate of hysterectomy following uterine artery embolisation?
2.9%
What side effect is associated with high doses of vitamin B6?
Peripheral neuropathy
What is the rate of haemorrhage at hysterectomy for benign conditions?
23 in 1,000 (common)
What are the risks associated with HRT?
VTE
Stroke
Breast cancer
Endometrial cancer
Ovarian cancer
Gallbladder disease
